Trauma in pregnancy

The anatomic and physiologic changes make treatment of the pregnant trauma patient complex. The fetus is the challenge, because, in pregnancy, trauma has little effect on maternal morbidity and mortality. Aggressive resuscitation of the mother, in general, is the best management for the fetus, because fetal outcome is directly related to maternal outcome. Recent literature has attempted, with little success, to identify factors that may predict poor fetal outcomes. Cardiotocographic monitoring should be initiated as soon as possible in the emergency department to evaluate fetal well-being. Other key points include: Maternal blood pressure and respiratory rate return to baseline as pregnancy approaches term. Initial fetal health may be the best indicator of maternal health. Inferior vena cava compression in the supine patient may cause significant hypotension. Maternal acidosis may be predictive of fetal outcome. Kleihauer-Betke testing is not necessary in the emergency department. Early ultrasonographic evaluation can identify free intraperitoneal fluid and assess fetal health. Necessary radiographs should not be withheld at any period of gestation. Radiation beyond 20 weeks' gestation is safe. Patients with viable gestations require at least 4 hours of CTM monitoring after even minor trauma.     

Myocardial infarction during pregnancy

Although myocardial infarction during pregnancy is not a common event, its occurrence is associated with significant morbidity and mortality for both mother and fetus. Multidisciplinary collaboration is required to individualize care. The presence of two patients (mother and fetus) must be acknowledged and the cardiovascular stress imposed by pregnancy and birth must be recognized. Nurses who care for these patients are required to integrate both cardiac and obstetrical knowledge and attend to psychosocial as well as physical needs. The impact of MI on maternal tasks of pregnancy, coping ability, maternal-fetal attachment, and adjustment to parenthood are certainly great but are beyond the scope of this article.     

Cardiac drug use in pregnancy: safety,effectiveness and obstetric implications

Morbidity and mortality due to cardiovascular disease is increasing in pregnancy. The physiologic changes of normal pregnancy serve as a ‘stress test’ on the cardiovascular system. This may lead to the unmasking of a latent underlying cardiac condition or the new onset of maternal cardiovascular disease, with an attendant increase in adverse maternal and fetal outcomes. Some women with pre-existing cardiac conditions may be receiving medications that need to be altered during pregnancy owing to a risk of adverse effects on the developing fetus, but for most cardiac conditions, there are safe and effective treatment options. Women should be educated that abrupt discontinuation of cardiac medications during pregnancy usually poses a greater risk than the medications themselves, and a plan of judicious drug selection should be implemented (ideally prior to conception).     

Promoting fetal stabilization during maternal hemodynamic instability or respiratory insufficiency

Fetal oxygenation is primarily determined by maternal oxygenation and uterine blood flow. Several physiologic adaptations during pregnancy support uteroplacental perfusion and, thus, fetal oxygenation. However, the physiologic changes required to sustain the metabolic demands of pregnancy may also predispose the parturient to decompensation when critical illness is superimposed upon pregnancy. In general, the critically ill gravid woman is treated similarly to the nonpregnant adult, with the exception of accomodating the physiologic changes of pregnancy and evaluating fetal well-being. An overview of the physiology of fetal oxygenation, impact of critical care interventions upon the fetus, and evaluation of the fetus is provided.     

Management of the obstetric patient with status asthmaticus

Status asthmaticus requiring mechanical ventilation is an uncommon, life-threatening disorder in obstetric patients. The unique physiologic changes of pregnancy, impact of the fetus on the maternal condition, and concerns for fetal and maternal health and survival are particular concerns in critical illness. Furthermore, the issues of hypoxemia and hypercapnia, ventilator management and complications make this disease of respiratory failure an especially important area for review. There is abundant literature on the management of asthma during pregnancy; however the literature is very limited in those with status asthmaticus who require intensive care unit admission. We report our intensive care unit experience in the management of status asthmaticus in 5 pregnant patients and review the literature on management of status asthmaticus during pregnancy.     

Burn injuries and pregnancy

Although burn injuries during pregnancy are considered relatively rare, the exact incidence is not known. Multiple factors influence morbidity and mortality resulting from burn injuries during pregnancy. These factors include the depth and size of the burn, the woman's underlying health and age, and the estimated gestational age of the fetus. Associated inhalation injury and development of other significant secondary complications also influence maternal and fetal outcomes. Successful burn care requires a team approach in which almost every healthcare discipline is represented. Initial care is almost always provided by a specially trained emergency medical team in an out-of-hospital setting. During this phase, the ability of the team to communicate with emergency hospital personnel facilitates appropriate clinical management at the scene. In addition, continued communication regarding the woman's status and responses to treatment allows critical care specialists within the hospital to ensure that necessary personnel and resources are available when the patient arrives. From the time the pregnant woman is admitted to a hospital for additional acute and critical care through the extensive process of rehabilitation from burn injuries, providing care often evokes strong emotions and requires specialized skills to achieve the most positive outcomes.     

State of the art prenatal care from the Swiss viewpoint

Prenatal care has significantly reduced perinatal and maternal mortality. Screening for maternal disease allows us to reduce or to prevent an unfavourable fetal or obstetrical outcome. Prenatal care should start with a first preconceptional visit. Folic acid intake is recommended for all reproductive-age women who are capable of becoming pregnant. The fetal nuchal translucency measurement has revolutionized prenatal care as a non-invasive, effective screening for chromosomal abnormalities and other diseases of the fetus. Vertical transmission of infections has to be prevented if possible. As an example caesarean section in combination with antiretroviral therapy reduces the transmission of HIV significantly. Screening for sexually transmitted diseases (STD) remains important as at present the incidence of STD is increasing again. In this short review on prenatal care as it is done in Switzerland, we try to enlighten its most important aspects. For the patients and your own benefit as a physician it is important to follow guidelines, although of course each patient has to be treated individually.     

Chronic renal disease and pregnancy

Women who have chronic renal disease are at increased risk for maternal and fetal morbidity and mortality during pregnancy. The severity of the renal disease is correlated with the degree of morbidity and mortality. Chronic renal disease ranges from asymptomatic bacteriuria (ASB) to end stage renal disease requiring hemodialysis and/or renal transplantation. Pregnant women with chronic renal disease require specialized nursing care. Communication between obstetrical nurses and renal nurses is extremely important to ensure holistic care of these patients.     

Critical care obstetrics: management of the fetus.

Whenever a critically ill gravida presents for care, consideration should be given to consulting an obstetrician or a maternal-fetal medicine specialist. The technological advances of the past two decades permit these critical care obstetrical specialists to immediately assess fetal health with ultrasonography or a fetal monitor. By so doing, maternal and fetal care can be optimized through a team approach.     

Diabetes in pregnancy: rationale and guidelines for care.

The management of pregnancy in a woman with diabetes is directed toward insuring a normal outcome for the mother and her newborn baby. There is ample evidence from studies in both humans and animals that maintenance of a normal maternal metabolic environment, particularly blood glucose concentrations, can avoid or ameliorate the complications of pregnancy responsible for increased morbidity and mortality in the mother and her baby. It is essential that this metabolic normalcy be achieved preconceptionally if congenital malformations, the leading cause of death in IDMs, are to be avoided. Thus, preconceptional care, intensive regulation of maternal glucose metabolism and fetal surveillance throughout pregnancy are critical. The use of the multidisciplinary team to optimize care has led to significant reductions in maternal and perinatal morbidity/mortality in IDMs, and is thus essential to successful outcomes in pregnancies complicated by diabetes.     

Special populations critical care considerations of the morbidly obese pregnant patient

The critically ill pregnant patient poses a unique challenge to the clinician, requiring a thorough understanding of normal and abnormal maternal and fetal physiology associated with pregnancy. The morbidly obese patient presents even greater challenges to the clinician, and morbidity and mortality are proportionately increased. Because increased numbers of obese pregnant women are now admitted to intensive care units, practitioners must be aware of the physiology associated with both pregnancy and obesity. A multidisciplinary approach is imperative to prevent both maternal and fetal morbidity and mortality for these very complex patients, especially when they are admitted to the ICU with critical illness.     

Pulmonary complications in pregnancy: considerations for care

Anatomic and physiologic changes of pregnancy predispose the mother to increased morbidity and mortality whereas increasing risks of a less than optimal outcome for the fetus. The frequency and significance of acute and chronic respiratory conditions in pregnant women have increased in recent years. Clinicians must have an understanding of cardiopulmonary physiology to promptly recognize and treat pregnant women with respiratory conditions ranging from asthma to adult respiratory distress syndrome. Hospitals must establish systems to assure timely assessment, multidisciplinary care, and possibly a plan for transfer to a higher level of care to provide highest quality care to the perinatal patient presenting with a severe respiratory condition to promote optimal outcomes for the woman and the fetus.     

Management of pregnant women complicated with idiopathic thrombocytopenic purpura

Idiopathic thrombocytopenic purpura(ITP) is occasionally manifested during pregnancy by routine prenatal screening for blood cell counts. Since ITP can potentially cause serious hemorrhage both in mother and fetus, the accurate assessments as well as appropriate clinical managements are necessary for successful delivery. Several guidelines were introduced to manage the maternal thrombocytopenia by ITP in pregnancy and in labor. However, there still remain several controversies regarding the indication of measurement of fetal platelet counts by fetal blood sampling, especially by percutaneous umbilical blood sampling, to decide mode of delivery. The current obstetrical managements and their potential limitation are discussed in this review.     

Trauma during pregnancy

Trauma is the leading nonobstetrical cause of maternal death. The effect of trauma on the pregnant woman and unborn fetus can be devastating. The major causes of maternal injury are blunt trauma, penetrating trauma, burns, falls, and assaults. There are specific changes associated with pregnancy that are important for the clinician to consider when providing care to these patients. Initial management of traumatic injuries during pregnancy is essential for maternal and fetal well-being. This review outlines common causes of maternal trauma, the initial assessment of the pregnant trauma patient, and ongoing care for the pregnant trauma patient and unborn fetus.     

Clinical review: Special populations - critical illness and pregnancy

Critical illness is an uncommon but potentially devastating complication of pregnancy. The majority of pregnancy-related critical care admissions occur postpartum. Antenatally, the pregnant patient is more likely to be admitted with diseases non-specific to pregnancy, such as pneumonia. Pregnancy-specific diseases resulting in ICU admission include obstetric hemorrhage, pre-eclampsia/eclampsia, HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome, amniotic fluid embolus syndrome, acute fatty liver of pregnancy, and peripartum cardiomyopathy. Alternatively, critical illness may result from pregnancy-induced worsening of pre-existing diseases (for example, valvular heart disease, myasthenia gravis, and kidney disease). Pregnancy can also predispose women to diseases seen in the non-pregnant population, such as acute respiratory distress syndrome (for example, pneumonia and aspiration), sepsis (for example, chorioamnionitis and pyelonephritis) or pulmonary embolism. The pregnant patient may also develop conditions co-incidental to pregnancy such as trauma or appendicitis. Hemorrhage, particularly postpartum, and hypertensive disorders of pregnancy remain the most frequent indications for ICU admission. This review focuses on pregnancy-specific causes of critical illness. Management of the critically ill mother poses special challenges. The physiologic changes in pregnancy and the presence of a second, dependent, patient may necessitate adjustments to therapeutic and supportive strategies. The fetus is generally robust despite maternal illness, and therapeutically what is good for the mother is generally good for the fetus. For pregnancy-induced critical illnesses, delivery of the fetus helps resolve the disease process. Prognosis following pregnancy-related critical illness is generally better than for age-matched non-pregnant critically ill patients.     

Unusual maternal vasculature in the placental periphery leading to the diagnosis of abdominal pregnancy at 25 weeks' gestation

Abdominal pregnancy is a rare condition in which the fetus and placenta are located within the peritoneal cavity. Sonographic findings include visualization of the fetus separate from the uterus, failure to visualize the uterine wall between the fetus and urinary bladder, close approximation of fetal parts to the maternal abdominal wall, eccentric position or abnormal fetal attitude, and visualization of extrauterine placental tissue. We present an unusual case in which mid-trimester transabdominal color Doppler sonographic findings depicted unusual maternal vasculature in the placental periphery leading to the diagnosis of abdominal pregnancy. Postpartum maternal angiography confirmed these vessels as abnormal maternal arterial perfusion of the extrauterine placenta emanating from the uterine arteries and inferior epigastric arteries. Systematic review of the literature confirms that this is the first report of such sonographic manifestations of an abdominal pregnancy.     

Variations of the concentrations of certain glycoproteins in maternal serum, fetal serum and amniotic fluid during pregnancy (author's transl)]

The authors investigated systematically the variations during normal pregnancies of the concentrations of alpha-1-antitrypsin, orosomucoid, transferrin and alpha-fetoprotein simultaneously in maternal serum, fetal serum and amniotic fluid. The role of certain factors such as the gestational age birth weight, placental weight and pairty were studied with regard to variations in the concentrations of each of these proteins. This research permitted the definition during pregnancy of the normal concentrations for these four proteins and allowed us to learn more about protein exchanges between fetal blood, maternal blood and amniotic fluid. There exists a difference between the concentrations of alpha-1-antitrypsin and of orosomucoid found for primigravidae and for multigravidae. The role of these glycoproteins in preventing the mother from rejecting the fetus (insofar as the fetus may be considered as an allograft) is discussed.     

Critical care obstetrics and gynecology

The critical care aspects of obstetrics and pregnancy are varied and demand that critical care practitioners have a thorough knowledge of fetal and maternal changes in physiology as pregnancy progresses. Pregnancy can affect every organ system; and organ-specific conditions as well as syndromes that span multiple organ systems were described. Care of the critically ill, pregnant patient requires a true multidisciplinary approach for optimal outcomes. A review of the current concepts and suggestions for therapy were presented.     

Fetal Sex,Need for Insulin,and Perinatal Outcomes in Gestational Diabetes Mellitus: An Observational Cohort Study

Purpose

This was a prospective observational cohort study that aimed to determine whether fetal sex influences the maternal and fetal outcomes of gestational diabetes mellitus (GDM).

Exchange of carbon dioxide in the pregnant rhesus monkey: multicompartmental analysis of carbon dioxide kinetics

The exchange of carbon dioxide in the pregnant rhesus monkey has been studied quantitatively using sodium bicarbonate-(14)C and applying the model of a system of seven compartments. The transfer rates among the various compartments, compartment sizes, and the rate of production of carbon dioxide by fetus and mother were determined with a computer programmed to fit the theoretical model to the data by adjusting the parameter values of the model until a "best fit" was obtained. It was confirmed that the exchange of carbon dioxide between fetal and maternal blood across the placenta is rapid, that between fetal blood and amniotic fluid is slow, and that there is no appreciable exchange between maternal blood and amniotic fluid. The mean net production of CO(2) by fetus was 0.476 +/-0.0402 mmoles/kg.min, and that by mother was 0.373 +/-0.0279 mmoles/kg.min.